Coagulopathy (main)

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Liver Disease

Background

  • PT prolongation
    • Decreased synthesis of vitamin K-dependent factors (II, VII, IX, X)
  • Thrombocytopenia
    • Portal hypertension -> congestive hypersplenism -> splenic sequestration
  • Fibrinolysis increased
    • Due to decreased synthesis of alpha2 plasmin inhibitor
    • Low fibrinogen level, mild elevation of FDP and D-dimer

Treatment

  1. Lab abnormalities only (w/o significant bleeding)
    1. Observation
  2. Significant bleeding
    1. Vitamin K PO or IV
    2. Desmopressin
      1. Effective w/ minimal side effects
      2. 0.3 mg/kg IV (preferred) or SC (max 20mg)
      3. Onset of action ~1hr, duration of action ~4-24hr
    3. Cryoprecipitate
      1. May be used to replace fibrinogen in pts w/ fibrinogen levels <100
      2. 1 bag per 10kg of body weight
    4. Plts
      1. Aim for >50K for moderate risk procedures; >100K for high risk procedures
    5. FFP
      1. Use w/ caution; requires large volume of FFP to make a significant difference
    6. PPI/pepcid/octreotide (variceal bleed)

Renal Disease

Background

  • Uremic toxins inhibit platelet aggregation
  • Dialysis may induce thrombocytopenia

Treatment

  1. Acute dialysis
    1. pRBCs
      1. Raising hct to above 25-30% improves bleeding time
    2. Desmopressin
      1. Simplest and least toxic acute treatment
      2. Increases release of factor VIII:von Willebrand factor multimers
      3. 0.3 mg/kg IV (preferred) or SC (max 20mg)
      4. Onset of action ~1hr, duration of action ~4-24hr
  2. Estrogen
    1. Unclear mechanism of action
    2. Onset of action within 1d
    3. Options
      1. Conjugated estrogen 0.6mg/kg IV or 2.5-25mg PO daily
  3. Cryoprecipitate
    1. Only indicated for life-threatening bleeding resistant to DDAVP and blood tranfusion
  4. Plt transfusion
    1. Minimally effective b/c infused plts quickly acquire the uremic defect


Source

  • Tintinalli
  • UpToDate